AgeWell New York Medicare Part D Pharmacy Benefits
Your Medicare Part D prescription drug plan rights including grievances, coverage determinations, exceptions and appeal processes are included in this section. Please refer to your plan Evidence of Coverage, for more detailed information.
Elixir is the company AgeWell New York uses to manage members’ prescription drug coverage for Medicare. You will see Elixir listed on your member ID card, In letters sent to you about your medicines and in the information listed below.
As an AgeWell New York member, you can call our pharmacy benefit manager, Elixir at 1-844-782-7670, 24 hours a day, 7 days a week, if you have any questions or concerns regarding pharmacy benefits, picking up or paying for your prescription medicines at the pharmacy, getting an emergency exception to our approved medicines list (formulary), obtaining information on the aggregate number of grievances, appeals, and exceptions filed with us, or any other questions about prescription medicines or medication supplies you may need.
A formulary is a list of prescription drugs (both generic and brand name) that are preferred by your health plan. Your health plan may only pay for medications that are on this “preferred” list, unless your health care provider talks with your health plan and gets prior approval.
Pharmacy Transition Policy
AgeWell New York wants to ensure your prescription drug transitions are safe and as easy to navigate. Please review the information below for guidance on any prescription drug transition.
Transition Fill Policyopens PDF file
Pharmacy Exceptions and Coverage Determinations
If you require a medication that is not on the AgeWell New York formulary and you cannot use a formulary alternative, or if you require an exception to one of our utilization management rules or tiered cost-sharing, you have the right to request a coverage determination. Review the information below to learn more.
Coverage Determination Request Formopens PDF file
Redetermination Request Formopens PDF file
Tier Exception Request Formopens PDF file
Non-Formulary Exception Request Formopens PDF file
Request for Reconsideration of Medicare Prescription Drug Denialopens PDF file
You may initiate a coverage determination:
- By phone at 1-844-782-7670
- Through Elixir website at elixirsolutions.promptpa.com
- By mailing your request to:
7835 Freedom Avenue NW
North Canton, OH 44720
Appoint a Representative
CMS Appointment of Representative Form Englishopens PDF file
Pharmacy Appeals and Grievances
It is the policy of AgeWell New York to provide meaningful procedures for timely hearing and resolution of grievances. This policy enables us to use listening and problem-solving skills to resolve the issue presented. The policy also provides a protocol for escalation of grievances when warranted or requested.
As a member of AgeWell New York, you have the right to request an appeal to review an adverse coverage determination made by AgeWell New York on the benefits that you believe you are entitled to receive
Learn more about Pharmacy Appeals and Grievancesopens PDF file
Submitting a Prescription Claim Form for Prescription Drugs Paid Out of Pocket
AgeWell New York wants to ensure you can access your prescription drugs when you are traveling or when your pharmacy processes your medications without using your Agewell Insurance. Please review the policy below for in-depth information.
Submitting a Prescription Claim Form for Prescription Drugs Paid Out of Pocketopens PDF file
Pharmacy Best Available Evidence
What is best available evidence?
Federal regulations specify the requirements of Part D sponsors in the administration of the low-income subsidy program, including the reduction of cost-sharing for subsidy-eligible individuals. In certain cases, CMS systems do not reflect a beneficiary’s correct low-income subsidy (LIS) status at a particular point in time. As a result, the most up-to-date and accurate subsidy information has not been communicated to the Part D plan. To address these situations, CMS created the best available evidence (BAE) policy. This policy requires sponsors to establish the appropriate cost-sharing for low-income beneficiaries when presented with evidence that the beneficiary’s information is not accurate. Call us at 1-866-237-3210 if you are eligible for low-income subsidy.
For more general information that is not specific to an individual plan, please view the following links:
The Formulary and/or pharmacy network may change at any time. You will receive notice when necessary.